A trio of case reviews have identified a series of failures by agencies who were involved with a vulnerable women and two teenagers who murdered her. But the reports concluded that her death could not have been prevented.
The two teenagers, aged 13 and 14, killed Angela Wrightson in December 2014. Two serious case reviews (SCRs) for Hartlepool Safeguarding Children Board, and a safeguarding adults review (SAR), for Teeside Safeguarding Adults Board, found professionals involved with all three individuals collectively failed to grasp the complexity of the situations they were dealing with.
The reviews uncovered instances of disjointed multi-agency working, missed opportunities to escalate concerns and, in the two girls’ cases, a mistaken focus on their behaviour rather than neglect on behalf of their parents. Nonetheless, they concluded that Wrightson’s murder “was not predictable and therefore not preventable”.
The SAR commented that the case of Wrightson, who had a dual diagnosis of a personality disorder and alcohol addiction, raised “fundamental issues” for professionals working with people with complex needs who present with significant risk in the community.
“The case reflects the ethical dilemmas around mental capacity, care pathways, commissioning for complex need and the challenges in understanding an individual in the context of their community and adult safeguarding,” the report said.
Wrightson, referred to in the SAR as ‘Carol’, lived alone at the time of her death on a street in Hartlepool that was notorious as an anti-social behaviour hotspot. She was primarily supported by an integrated mental health team, including three social workers who were AMHP trained, but was also well-known to other agencies.
In the two years leading up to her murder she had an estimated 1,000-plus contacts with mental health, alcohol and ambulance services, hospitals and others.
Local police community support officers (PCSOs) were regular visitors to her addresses, where they would help to clear out unwanted visitors – who included sex workers operating there without Wrightson’s consent, and local youths who would congregate to drink and take drugs. Wrightson “had some form of agency contact practically every day, often when intoxicated”, the SAR found.
Despite this constant contact, different professionals “understood and responded to her with differing perspectives,” the review noted.
“Across the agencies, there was a great deal of disparity of knowledge of Carol’s personality disorder or whether she had mental illness at all,” the report said. “Some agencies were genuinely surprised to learn that Carol had a personality disorder and many professionals did not understand what that meant for their work with Carol or how this might need to influence how an individual may need to be managed.”
In April 2012 the integrated mental health team put together a “comprehensive and thoughtful” case for her to be moved to a specialist placement away from Hartlepool.
“It has been identified by all professionals currently involved with Carol that her safety and mental and physical well being cannot be maintained in the community setting and the only appropriate option is a period of structured, supported inpatient care,” the mental health social workers argued.
But they were uncertain as to exactly what process needed to be followed and a placement in Bradford, which Wrightson worked hard to reduce her drinking to be ready for, fell through at the last minute in August 2012.
“Even now, there is some confusion and differing recollections as to why the Bradford placement did not come to fruition, but whatever the reason this had a significant [negative] impact upon Carol,” the SAR found.
During the following year Wrightson experienced many problems with young people using her house and “pressing her” to buy them alcohol and cigarettes. While PCSOs assisted her frequently, she was “not seen as a victim” as she was judged to be exercising choice in letting people in, and was deemed to have mental capacity when not intoxicated.
“The integrated mental health team state they made mental capacity assessments of Carol, but more informally,” the SAR found. “Her mental capacity was complex and multifactorial but this was seen in more narrow terms at the time.”
Over the summer of 2013, the review noted “a number of concerning incidents which should have resulted in a full adult safeguarding investigation and a multi-agency strategy consideration”.
These included reports by Wrightson of serious sexual assaults on her, and her having a black eye and being scared to go home because of the people who came there. Some of these, she described as “schoolies”.
While the mental health team did subsequently raise safeguarding alerts, these were referred back to them as the party best able to take things forward, meaning that information was never shared in as wide a forum as it might have been. The review also found that “among the professionals and agencies working with Carol there was not, nor is there currently, a common understanding of adult safeguarding thresholds”.
In late 2013 Wrightson moved to her final address, a private rented house at which incidents involving young people continued to escalate. While the street had been designated a crime and disorder hotspot, a lack of information sharing – including between police teams – and further missed opportunities to make further safeguarding referrals, meant that a complete picture of the risks she was exposed to was never established.
“It is not known if the girls who murdered Carol were part of the group of young people who were at times in her home,” the SAR concluded.
The girls who killed Wrightson, identified as ‘Olivia’ (14 at the time of the murder) and ‘Yasmine’ (13) in the two SCRs, were also found to have been supported by professionals who formed incomplete pictures of them – described in Yasmine’s case as ‘fixed thinking’.
Both girls had experienced damaging neglect, which was not immediately apparent to professionals. But they were made subject to plans that largely centred on rectifying their behaviour, which included aggression, bullying, drinking, drug use and sexual activity. Their parents consistently drew professionals’ attention to the girls’ unmanageability while themselves failing to engage with services – which too often went unchallenged.
A series of findings common to both SCRs noted:
- Insufficient understanding of adolescent neglect “across the multi-agency network”
- Professionals “struggling” to provide an effective service to teenagers with complex needs
- A tendency for professionals to sympathise with parents’ perspectives, leaving emotional abuse undiagnosed
- Too much focus on support services to keep children with their families; too little on the level to which parents engage with those services
Nonetheless, both SCRs noted “support from a consistent, caring and hardworking group of professionals”. The reviews found that no linear narrative should be drawn between either teenager’s increasingly chaotic situations and Wrightson’s death.
At the time of the murder both had been taken into care, with Olivia in a specialist children’s home and Yasmine in a foster placement, and had been discussed at a local Vulnerable, Exploited, Missing and Trafficked (VEMT) group. Just one prior incident, in June 2014 when Yasmine made unsubstantiated claims to have spent a night at Wrightson’s house after going missing, was found to link either girl to their victim.
Dave Pickard, chair of Hartlepool safeguarding children board, said: “Neither young person had a criminal history [nor a] history of any significant assaults on any other individuals.
“Their behaviour was troublesome and anti-social before the night in question, but there was no suggestion whatsoever of any serious violence – it was a total shock to everyone.”
Ann Baxter, chair of the Teesside Safeguarding Adults Board (TSAB), acknowledged that organisations involved with Wrightson “could have shared more information and could have been more coordinated – and we are looking at how those organisations can work better together to share the intelligence that they have.”
Baxter added: “Since Carol’s death in 2014, work has been carried out to ensure more information is shared between agencies, but unfortunately that still can’t prevent the unforeseeable and unexplainable and sadly that is what happened on the night in question.”